Volume 2025 | No. 2
SURVEYOR
RENAL DIALYSIS
■ The facility did not ensure that reverse osmosis systems were meeting the requirements of AAMI 5.2.2, Table 1 when tested with the typical feed water. ٝ Location 1 - The RO 2 product conductivity range is 1-20 mS. On several dates it was documented out of range (22- 24). Additionally, the rejection range is >90%, however on several dates there is no documentation of this parameter. ٝ Location 2 - The RO prefilter differential delta pressure range is <10. It was noted as “10” on nine occasions in June, nine occasions in July, and 10 occasions in August with no documentation at either location of trending analysis or interventions regarding the documented out of range measurements.
Compliance tips for:
The standard focuses on infection prevention training with the goal of consistent implementation of infection prevention practices across the organization. ■ Audit policies and procedures for catheter and catheter-site care to ensure they: ٝ define appropriate cleaning/disinfections of the caps used to close the catheter between uses. ٝ define expectations for dressing changes. ٝ identify signs and symptoms of infection that should be reported – by staff, patients, caregivers. ■ Monitor personal for compliance with infection prevention practices. ■ Conduct regular refresher trainings on infection prevention topics. ٝ Engage staff with “spot-the-error” scenarios.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Compliance tips for:
The facility must be able to demonstrate that water and equipment used for dialysis meets quality standards and requirements from in the Association for the Advancement of Medical Instrumentation publication “Dialysate for hemodialysis,” ANSI/AAMI RD52:2004. ■ Audit water and dialysate logs for full and accurate documentation of requirements. ■ Conduct semi-annual training with relevant staff. ■ Hang laminated reminder signage in the appropriate areas to prompt staff on acceptable ranges and documentation requirements.
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
RD7-E Frequency of the citation: 26%
Nerd Trailblazers (prepare the path for others)
Overview of the requirement: The organization must achieve standards set by AAMI for water and dialysate quality. Note: This standard is only applicable to in-center dialysis.
RD7-J Frequency of the citation: 33%
Comment on deficiencies: Compliance is assessed through review of written policies and procedures, monitoring and testing records, response to interview, and observation. The elements of the standard are lengthy and detailed. Surveyors cited a range of specific deficiencies. The only concern repeated on multiple surveys was unrestricted access to the purification and storage system. Examples of ACHC Surveyor findings: ■ The facility did not provide evidence that it follows the manufacturer guidelines for system disinfection per AAMI 5.3.3. There was no documentation of hot water disinfection of machines on the required schedule. ■ There is no documentation of dialysate cultures being obtained for the month of November. ■ The water purification and storage system was not located in a secure area with access to the purification system restricted to individuals responsible for monitoring and maintenance of the system.
Overview of the requirement: The treatment environment is designed, equipped, and maintained to be safe, functional, and comfortable for patients, staff, and visitors. Comment on deficiencies: Compliance is assessed primarily through direct observation. Surveyor comments focused on the layout of patient care areas and deferred maintenance of equipment that compromised safety. Examples of ACHC Surveyor findings: ■ Patient rooms in this LTC facility are semi-private with two to three patients located in each room. During the survey, there were two patients dialyzing at the same time in each room. The waste lines/tubing were run from the machine into the restroom, then were taped to the toilet seat for waste disposal. Facility staff entering and exiting the rooms multiple times were carefully watching their footing. The tubing is not taped or secured to the floor creating a clear tripping hazard.
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